Provider Demographics
NPI:1871850099
Name:VAN GILST, CHERYL LYNN (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:LYNN
Last Name:VAN GILST
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 BLACKBERRY LN
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-9513
Mailing Address - Country:US
Mailing Address - Phone:505-238-5370
Mailing Address - Fax:
Practice Address - Street 1:21 BLACKBERRY LN
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-9513
Practice Address - Country:US
Practice Address - Phone:505-238-5370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3204235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist